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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �01]. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/os install the work herein described.This application is V" <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 3 \ City Lot Size PM <br /> Job Address (1`; <br /> I� <br /> Address Phone <br /> Owner's Name <br /> Phone <br /> Contractor's Name <br /> License No. <br /> TYPE OF WELL/PUMP:' IFi NEW WELL,-© WELL REPLACEMENT 13 DESTRUCTION C1PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRI LTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE.OF WELL PROBLEM AREA CONST CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ' - ❑rManteca D Well Excavation pia. of Well Casing <br /> Specifications <br /> ❑ Domestic/Private E3Gravel Pack ❑ Tracy k pe Casing <br /> ❑ Public ❑ Other ❑ Delta Depth of ut Seal Type of Grout <br /> ❑ Irrigation _ �Approx. Depth ❑ Eastern Surface Seal Ins <br /> Repair Work Done ❑ Type of Pump P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 LJ� <br /> 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ D STRUCTI( alvailableseptic <br /> wthin 200 feet.) if public sewer.is <br /> I <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> a li <br /> r <br /> f LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r <br /> FILTER BED [71Distance to nearest: Well Foundation Property Line � <br /> µ <br /> SEEPAGE PITS ❑ 'Depth Size Number n <br /> I ❑ 'Distance to <br /> SUMPS nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C] <br /> F I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." 4 <br /> The applicantmustcall fore all required inspections. /Complete drawing on reverse side. <br /> Signed !l i 'r✓ . lit'G K' Y Title:— �+illv► r� Date: <br /> FOR DE2=RTMENT USE ONLY <br /> Application Accepted by <br /> Date <br /> Area � <br /> Pit or Grout Inspection by Date Final inspection by n� � <br /> `- Date <br /> Additional Comments: <br /> 11 Stk 466-6781 13 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> !UNT DUE AMOUNT REMITTED CA3Ff RECEIVED BY DATE PERMIT"�O. <br /> INFO <br /> + EH 13-24{REV.101831 <br /> EH 14-26 <br />